A 40 year old lady presented
with a 10 day history of breathlessness, palpitations and chest tightness. The
palpitations were short-lived, regular and rapid, and associated with pre-syncope.
She visited her local general physician who organised some routine blood tests
and a Chest X-ray which revealed cardiomegaly, bilateral opacification and bilateral
pleural effusions consistent with congestive heart failure. Based on these
results, the physician advised hospital admission.

On initial examination, her
blood pressure was 100/70 and her Jugular Venous Pressure (JVP) was elevated to
her earlobe. She had reduced air entry and crepitations auscultated at both
lung bases. An electrocardiogram (ECG) revealed markedly low amplitude QRS
complex with an incomplete right bundle branch block morphology. Serum blood
analysis revealed normal routine blood tests including inflammatory markers.
High Sensitivity Troponin T was elevated at 2788mmol/L. She was transferred to the Coronary Care Unit
at our hospital.

She had a significant occupational
exposure to wildlife, including recent travel to Eastern Europe to study bats
several months prior to admission. She was a non-smoker with minimal alcohol
intake and no significant past medical history of note.

Aggressive intravenous
diuresis was commenced with an initial clinical improvement. Urgent cardiac
magnetic resonance imaging (MRI) was requested and the case with discussed with
the local transplant centre who accepted for transfer and assessment. Despite
aggressive diuresis, over the next 3 days she continued to increase in weight
with a persistently low blood pressure. There was worsening derangement of
renal and hepatic function. She was commenced on intravenous dobutamine and noradrenaline
and transferred emergently to the transplant centre.